Skin Survey by Lorena Welcome to your Skin Analysis First & Last name Email Phone (no spaces or hyphen- ) 1. What is your skin Type? Combination Dry Oily Normal Not sure 2. What is the CONDITION of your skin? Acne Sensitive Dry Discoloration (brown spots) Clogged pores Lines and wrinkles Rough, textured skin Ingrown hairs & red pumps (Men) 3. Have you consulted your Doctor regarding any of these conditions? Rosacea Sensitive Skin Neither Not sure 4. SensitivityHow would you rate your sensitivity to skin care products? Very Sensitive Sensitive Not really sensitive Don't get a reaction 5. Acne:What level do you think your break out is? Blackheads and Whiteheads Blackheads, Whiteheads & some red pimples Blackheads, Whiteheads, red pimples all over Blackheads, Whiteheads, Pimples and Cystic No break outs 6. What is your age group? 18 & under 19-25 26-35 36-55 55 & up 7. Lines & Wrinkles:Where do you see these unwelcomed lines and wrinkles? Crows Feet Eyes- around and under Smile lines Neck Furrows- between brows Forehead Not sure All of the above NoneComments 8. What may have caused your discoloration (aka hyperpigmentation) (dark spots)? Acne Sun Hormones Pregnancy injury- (waxing, burn etc.) Laser Not sure I don't have any dark spots 9. Are you interested in Virtual Consultation?$145($100 can be applied to products)How it works:After purchasing Consultation $145. We will set up an appointment time on zoom. We will discuss the options for your skin and answer any more or detailed questions. You will receive $100 credit towards your skin care products Yes No Not sureComments 10. What profile best describes your skin. A guess is ok. 🙂 1-Very Fair 2- Fair 3- Medium 4- Olive 5-Brown 6-Black Not sure October 16, 2021Anything else we should know about you?
